Ohio Cyber Academy Enrollment Form

Enrollment Form
Student Information
Student's Legal Name

First NameMiddle NameLast Name
Grade Level
Gender
Birthdate

MonthDayYear
Date
Birth City
*Birth City is required solely to obtain a confidential student identification number.
Is the student identified as:
Is the student currently:
Admission Reason:
If you checked the box (transferred from non-public school) please enter the school name:
If you checked the box (transferred from another Ohio public, community, or online school) please enter the school district name:
**Grade placement subject to adjustment upon receipt of previous school records.
Required by the U.S. Department of Education
Race/Ethnicity:
Is the student Hispanic/Latino?
What is the student's race? (Choose all that apply):
Home Internet Access
Select the option that best describes how you receive you home internet service. (Choose only one.)
Household Information:
Residence address of student

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ohio County in which the student resides:
Primary Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Student resides with:
**Please provide all legal documentation for divorce/custody/guardianship. **Student must provide proof of emancipation.

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If student resides with anyone checked above, other than Mother and/or Father, you would like to disclose that information, please list their name, relationship to the student, and emergency contact number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Information:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Student:
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Living with Student?
Active Military?
Address (If different than student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father/Guardian Information:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Student:
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Living with Student?
Active Military?
Address (If different than student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List all other siblings or step-siblings under the age of 22 who reside in the students' home. (Name, Gender, DOB)
Should be Empty:

Enrollment Form

Student Information

Required by the U.S. Department of Education

Home Internet Access

Household Information: